PROJECT SUMMARY/ABSTRACT ? Exploring Institutional Variability in Neuro-prognostication for Survivors of Cardiac Arrest Survival and neurological recovery after cardiac arrest are highly variable, driven in part by inconsistent hospital care following successful resuscitation. Data from both in- and out-of-hospital cardiac arrest patient populations have shown variable application of evidence based post-cardiac arrest guidelines, including recommendations for delayed neuro-prognostication, defined as at least 72 hours after return of spontaneous circulation. Reasons for lack of provider adoption of these recommendations have included poor knowledge of the current guidelines, perceptions of poor neurologic recovery for post-arrest patients and surrogate decision makers wishes for early prognostication. To that end, our research team has ongoing work to implement a decision aid to support such processes. The purpose of this grant proposal is pre-implementation research to learn about the organizational culture and workflow at hospitals that have variable rates of utilization of early ?Do Not Resuscitate? (DNR) orders. This work will uncover potential barriers and facilitators to implementation of a guideline based decision aid and will allow for a better appreciation of the practice of neuro- prognostication for post-cardiac arrest patients in a more generalizable fashion. To support this overall research mission, we propose the following specific aims in this R03 proposal. The first study aim will explore the variability in utilization of early DNR by hospital in a US multi-center registry of in-hospital cardiac arrest. This analysis will provide understanding of how variable institutions are in their application of DNR as a potential surrogate for the practice of neurological prognostication. In Aim 2 of this research proposal, we plan to conduct a qualitative case study of institutions with variable rates of utilization of early DNR, with some centers reporting high utilization and others reporting low utilization. Centers will be purposively targeted that have different characteristics, including rural versus urban, academic versus non-academic and low versus high volume of cardiac arrest patients. We will interview physicians, nurses and social workers to learn about potential facilitators and barriers to the implementation of a decision aid to support families in making decisions for comatose survivors of cardiac arrest. Our overall objective is to improve the practice of guideline concordant decision making for comatose survivors of cardiac arrest that will encourage delayed neuro- prognostication and allow for sufficient time to awaken from cardiac arrest. By learning from cardiac arrest stakeholders at institutions that practice differently, our study team will be able to adapt our implementation strategy to promote better adoption of the decision aid. Results of this proposal will inform future work aimed at improving the quality of decisions made for comatose survivors of cardiac arrest and to improve neurologic outcomes for cardiac arrest survivors.